PNR 202/PNR202 Exam 4 V3 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer an isotonic intravenous solution. Which of the following
solutions should the nurse anticipate using?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
C. 10% Dextrose in Water
D. 0.9% Sodium Chloride
Correct Answer: D
Expert Explanation: 0.9% Sodium Chloride, also known as Normal Saline, is an isotonic
solution with an osmolarity similar to that of blood plasma. Isotonic solutions are used to
expand the extracellular fluid volume without shifting water between compartments. This
makes it the standard choice for initial volume replacement during dehydration or blood
loss.
2. During an IV assessment, the nurse notes the insertion site is cool to the touch, swollen,
and pale. Which complication should the nurse document?
A. Phlebitis
B. Infiltration
,C. Extravasation
D. Thrombosis
Correct Answer: B
Expert Explanation: Infiltration is the leakage of non-vesicant IV fluid into the
surrounding subcutaneous tissue, characterized by coolness, edema, and pallor. Phlebitis
would instead present with warmth and redness along the vein path. The nurse must stop
the infusion and remove the catheter immediately when infiltration is suspected.
3. A patient receiving a blood transfusion begins to experience chills, low back pain, and
hypotension. What is the priority nursing action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
C. Notify the physician
D. Administer an antihistamine
Correct Answer: B
Expert Explanation: These symptoms are classic indicators of a hemolytic transfusion
reaction, which is a medical emergency. The nurse’s first priority is to stop the transfusion
to prevent further administration of incompatible blood. After stopping the blood, the
nurse should maintain the IV line with normal saline and alert the provider.
, 4. What is the primary purpose of using a hypotonic IV solution like 0.45% Sodium Chloride?
A. To move water from the cells into the vascular space
B. To move water from the vascular space into the cells
C. To maintain a constant intravascular volume
D. To increase the osmolarity of the plasma
Correct Answer: B
Expert Explanation: Hypotonic solutions have a lower osmolarity than plasma, causing
water to leave the intravascular space and enter the intracellular space. This helps treat
cellular dehydration by rehydrating the cells themselves. However, nurses must monitor
closely for signs of fluid volume deficit in the vascular system.
5. A nurse is monitoring a patient for signs of fluid volume excess. Which clinical finding
should the nurse report?
A. Flattened neck veins
B. Decreased blood pressure
C. Distended jugular veins
D. Poor skin turgor
Correct Answer: C
Expert Explanation: Distended jugular veins (JVD) are a hallmark sign of fluid volume
excess, reflecting increased pressure in the venous system. Other signs include bounding
Therapy Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer an isotonic intravenous solution. Which of the following
solutions should the nurse anticipate using?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
C. 10% Dextrose in Water
D. 0.9% Sodium Chloride
Correct Answer: D
Expert Explanation: 0.9% Sodium Chloride, also known as Normal Saline, is an isotonic
solution with an osmolarity similar to that of blood plasma. Isotonic solutions are used to
expand the extracellular fluid volume without shifting water between compartments. This
makes it the standard choice for initial volume replacement during dehydration or blood
loss.
2. During an IV assessment, the nurse notes the insertion site is cool to the touch, swollen,
and pale. Which complication should the nurse document?
A. Phlebitis
B. Infiltration
,C. Extravasation
D. Thrombosis
Correct Answer: B
Expert Explanation: Infiltration is the leakage of non-vesicant IV fluid into the
surrounding subcutaneous tissue, characterized by coolness, edema, and pallor. Phlebitis
would instead present with warmth and redness along the vein path. The nurse must stop
the infusion and remove the catheter immediately when infiltration is suspected.
3. A patient receiving a blood transfusion begins to experience chills, low back pain, and
hypotension. What is the priority nursing action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
C. Notify the physician
D. Administer an antihistamine
Correct Answer: B
Expert Explanation: These symptoms are classic indicators of a hemolytic transfusion
reaction, which is a medical emergency. The nurse’s first priority is to stop the transfusion
to prevent further administration of incompatible blood. After stopping the blood, the
nurse should maintain the IV line with normal saline and alert the provider.
, 4. What is the primary purpose of using a hypotonic IV solution like 0.45% Sodium Chloride?
A. To move water from the cells into the vascular space
B. To move water from the vascular space into the cells
C. To maintain a constant intravascular volume
D. To increase the osmolarity of the plasma
Correct Answer: B
Expert Explanation: Hypotonic solutions have a lower osmolarity than plasma, causing
water to leave the intravascular space and enter the intracellular space. This helps treat
cellular dehydration by rehydrating the cells themselves. However, nurses must monitor
closely for signs of fluid volume deficit in the vascular system.
5. A nurse is monitoring a patient for signs of fluid volume excess. Which clinical finding
should the nurse report?
A. Flattened neck veins
B. Decreased blood pressure
C. Distended jugular veins
D. Poor skin turgor
Correct Answer: C
Expert Explanation: Distended jugular veins (JVD) are a hallmark sign of fluid volume
excess, reflecting increased pressure in the venous system. Other signs include bounding
